In recent years, federal payments to Medicare Advantage plans, and how they are adjusted for enrollee health status, have come under increased scrutiny. This brief answers key questions about coding intensity, recent steps taken by CMS to address the impact of coding on payment, the effects on Medicare beneficiaries, and other proposals to improve Medicare…
It’s not low effort or underinvestment. It’s the steady-state output of an organization succeeding at the wrong thing. The post The Hidden Cost of “Good Enough” in Healthcare Experiences appeared first on MedCity News.
Protego Biopharma’s lead program is a potential treatment for the rare disease light chain amyloidosis. The startup says the novel mechanism of its oral small molecule should have better outcomes than antibodies from AstraZeneca and Prothena that failed their respective pivotal studies in the disorder earlier this year. The post Startup Protego Bio Lands $130M…
Centers for Medicare & Medicaid Services (CMS) and most private payers in the U.S. have accepted the NCCN guidelines as a mandated reference to determine payment for “off‐label” use of anticancer drugs that are not approved for the specific indication by the U.S. Food and Drug Administration. Thus, a key question is what types of…
EY report shows a $9 increase in benefits from the prior year
This brief analyzes federal transparency data released by the Centers for Medicare and Medicaid Services (CMS) on claims denials and appeals for non-group qualified health plans (QHPs) offered on HealthCare.gov in 2023. It finds that HealthCare.gov insurers denied nearly one out of every five claims (19%) submitted for in-network services. Information about the reasons for…
CELO COMMUNITY, N.C. — On a 15-degree morning in January, a clinic in the Appalachian Mountains of North Carolina began to fill up with patients. An older couple in flannel pajamas sat together in the waiting room. A toddler waved as Patricia Hall walked past him, a stethoscope draped over her neck. The family physician…
Detailed information on immunizations for adults covered under the ACA.
Seasonal work. Inconsistent hours. Frequent moves. Cash payments and informal jobs. For farmworkers who rely on Medicaid, these common employment patterns could put their health coverage at risk. It’s a heightened concern for the estimated million-plus farmworkers who are U.S. citizens or legal permanent residents, as new work requirements kick in for the federal-state healthcare…
To meet the modern patient where they are, we must pivot away from managing chronic diseases to preventing them entirely, replacing a legacy system of triage with a new model that emphasizes proactive, personalized prevention. The post From Management to Personalized Prevention: The Phase Shift in Chronic Disease appeared first on MedCity News.